Dr Andy Blauvelt on Psoriasis Guidelines, Severity Definitions, and Treatment Strategies

In this podcast, Andrew Blauvelt, MD, MBA, discusses the updated guidelines for psoriasis, his work to help redefine how we classify psoriasis disease severity, and more. Dr Blauvelt is president and owner of Oregon Medical Research Center in Portland.

Transcript

Lauren:  Hi, and welcome to another episode of "The Derm Editor's Corner." I'm Lauren, the managing editor of The Dermatologist. Today, I'm speaking with Dr Andy Blauvelt, president and owner of the Oregon Medical Research Center in Portland. Let's get right to it.

What are the purpose of the guidelines that are published in the Journal of American Academy of Dermatology, published in partnership with the AAD and the National Psoriasis Foundation, and have they been useful in your practice as a clinician and thought-leading clinical trial investigator?

Dr Andy Blauvelt:  Doctors place a lot of emphasis on the psoriasis guidelines. Unfortunately, they haven't been updated very often over the years, so with psoriasis therapies changing so rapidly, we've had, for example, outdated guidelines for 5, 6, 7 years, and that has really been the problem in the past. On the other hand, we have some new guidelines that have recently come out, so that's a good thing. The way I see them is not so much as guidelines on how to practice with your patients with psoriasis, because they don't really provide algorithms. They actually give you a good overview of each of the treatment options that are available and the places where you might want to use them, or places where you might not want to use them on a given patient. A lot of great general information, but not a lot of specifics about what to do for an exact patient sitting in front of you.

Lauren:  How do you approach care for the patient that might prefer a topical as their treatment of choice for their psoriasis?

Dr Blauvelt:  Lauren, before I answer that, I want to just talk about how I approach patients in general. I've been working with the International Psoriasis Council to come up with new guidelines for the classification of psoriasis severity. Basically, what we've come forward with is this idea that patients should be placed into two buckets, either candidates for topical therapy, as you just asked, or candidates for systemic therapy. We really don't like the designations of mild, moderate, and severe, because they're not well-defined.

People can't agree what mild, moderate, and severe mean. Is this patient going to be treated with topicals, or is this going to be a systemic-treated patient? The things I use to help define a topical-treated patient would be patients with a low body surface area, anything below 10%, but they also have to have no disease in special areas. Special areas like palms and soles, the genitalia, the face, the scalp, I place more emphasis on those areas. I tend to go to a systemic agent if patients have disease in special areas, even with a low BSA.

Then failure of topicals, so let's say a patient comes in. For years, they've been using clobetasol or a potent steroid. They hate it, and the lesions are not responding anymore. Even if they have a low body surface area, I consider that patient actually a candidate for systemic therapy because of that known failure of good topical therapy. If the patient does fit into that category, we've got a number of things. The mainstay for me and for many dermatologists is potent topical steroids. Potent topical steroids is my first choice for a patient with limited psoriasis or is a candidate for topical therapy. I usually tell them to use it twice a day until the lesions clear and then to stop. I think you get into thinning of the skin when patients continue to use it, even though lesions have gone, and you can get into problems there.

Many times, I will add—not replace, but add—a topical vitamin D analogue or a topical retinoid with the topical steroid. It usually makes it work better and can reduce the burden or the need for topical steroids. That works well. I don't like to use those agents alone, though, the vitamin A and vitamin D analogues.

Interestingly, we have some new good topicals coming that may change this equation a little bit, but that's in general what I do with patients who are candidates for topical therapy.

Lauren:  When it comes to phototherapy, then, which is obviously a very different modality, what do you maybe consider? It's obviously, again, going back to that patient preference idea, is phototherapy going to fit into their schedule, and is it easy? What do you recommend, and how do you use phototherapy?

Dr Blauvelt:  The patient that fits for phototherapy, in my view, has been decreasing more and more with time, and you actually see fewer and fewer offices offering phototherapy. It's also become difficult lately to get it approved, and you can have repeated costs with each treatment, especially if it's being required every two to three times a week. Then the copay burden can be significant. The type of patient where this might work well is the ones who have too much disease to be using topical therapy, but they really are shy about a pill or a shot, and they have the time. They have the time to come in, or they have the money and the space in their home to have a home UVB unit. That, from my experience, is actually these days a pretty narrow patient population who doesn't want a pill or a shot, because we have such great shot options, actually, biologic options these days.

We know phototherapy is not great for those who are fair-skinned or may be prone to skin cancer and scalp psoriasis. It's not going to do anything for psoriatic arthritis. It has to be the right kind of patient, where we would go with phototherapy.

Lauren:  It's actually interesting you said that. One of the things I was reading was a little bit about mycosis fungoides risk in psoriasis patients. Again, phototherapy, probably not the strongest idea, going in those patients and exposing them within those skin cancers. I know that there's a second study that we're hopefully doing a piece on about MF and melanoma and things like that. It's interesting to see everything connect.

Dr Blauvelt:  In that regard, we think more of nonmelanoma skin cancers with phototherapy, like basal cells and squamous cells and melanoma risk for PUVA patients. We don't really think about CTCL or lymphoma risk with phototherapy use.

Lauren:  If we want to segue a little bit, these questions are a little bit more about systemic agents, unless you'd like to focus a little bit about the fail-first approach, which touches on the topic that you mentioned before of severity isn't a very linear piece. It's really multicomponent.

Dr Blauvelt:  I think what we're getting at here is let's say a patient, in my mind, is a candidate for systemic therapy, and we have issues with the insurance company, with a payer who says, "No, you can't use this drug you want to use. You've got to go X, Y, and Z first." Maybe sometimes, it'll be failure of topical therapy or a phototherapy trial before they'll approve a systemic agent. I hate that. It's called step therapy, and step therapy, to me, forces patients through often less-effective and often less-safe drugs before getting to the better and more safe drugs, which intuitively doesn't make any sense to me.

Why put people through less-safe, less-effective things? The bottom line, everybody knows, it's money. Those steps would not be in place if the best treatments were cheap. What we know now is the best treatments are not cheap. They're expensive. It's purely about money. It's really not about the patient or what's best for the patient when you see those step therapy guidelines. I hate them, and I try to fight them every chance I can.

Lauren:  Speaking of that, in touching on some of the biologic agents that we know are effective and incredibly safe, how do you—especially given, again, your background, and being basically, it seems like, on every clinical trial for these things -- you probably know them in and out at this point—how do you approach the biological agents and maybe how to choose what patient is right or what biologic, rather, is right for your patient?

Dr Blauvelt:  It's a really good question. It's the most common question I get when I speak about psoriasis therapy, is, "I get overwhelmed. Where do I start? Do I need to know all of these drugs?" I'd like to try to simplify it.

For general dermatologists, practicing dermatologists, so they don't get overwhelmed, and they actually pick up some real, practical things that will help their patients, I group the drugs into three categories. There's 11 of them now, 11 biologics FDA-approved for psoriasis. That's a lot. It can be overwhelming. "Do I need to know everything about all 11?" The answer is no, you don't.

The first class is the oldest class. That's the TNF blockers or TNF inhibitors. We all know those drugs: etanercept, adalimumab, certolizumab, and Remicade. Those drugs were great when they came out, but from the beginning, from the get-go, they had boxed warnings. They still have the boxed warnings for serious infections, for cancers, including lymphoma. Then there's other things that are not good with those drugs, like hepatitis B reactivation, TB reactivation, the rare occurrence of multiple sclerosis. That's a whole bunch of things I just said for TNF blockers. In general, they're pretty good and pretty safe, but in my mind, we've really, really made major advances with the IL-23 blockers and the IL-17 blockers, the two other big classes of biologics. 

One of the main teaching things is you can't say, "Biologics do this. Biologics do that." There are distinct mechanisms of action, and each mechanism of action has its own effects on the body and its own side effect profile. The TNF blockers, they're older, they're less safe, and they're less effective. Then we've got IL-23 and IL-17 blockers. There are terrific drugs in each of these classes. I use both classes of these drugs. The bulk of my patients, the majority, are on an IL-23 blocker or an IL-17 blocker. One of the big advantages of those two classes over TNFs is they don't have a serious infection boxed warning, and they don't have cancer warning. There's no worries about cancer or serious internal infections with the 23 and the 17 blockers. It's a big difference, and there's no MS, and there's no TB reactivation, and there's no hep B reactivation. A lot of this messiness from the TNF blockers, we don't see with these other two groups. Then between the 23s and 17s, both really safe, both really effective groups of drugs.

The only major difference is inflammatory bowel disease. If a patient has IBD, you want to avoid an IL-17 blocker. In that case, an IL-23 blocker, though, would be an excellent choice, because it's not associated with IBD exacerbation. That's one of the key differences between 23s and 17s. Otherwise, they're both really great classes of drugs for patients with psoriasis. If you pick one or two in each of those categories and learn those, your patients will greatly benefit. That's usually what I recommend.

Lauren:  Some patients, obviously, going back to that insurance point, biologics may not be an option when it comes to patient out-of-pocket cost or insurance coverage. How do you maybe use some of those systemic non-biologic agents in that place?

Dr Blauvelt:  I trained in the 1980s and 1990s, and we didn't have biologic agents then, so I'm very familiar with all of these drugs. Methotrexate, cyclosporin, acitretin, our good, old friends from the 1980s and 1990s. I used a lot of those drugs during that time period.

All of them have, I would say, limited to OK efficacy, but significant toxicity-related issues. Methotrexate, you have to worry about liver dysfunction, drops in blood counts, lung dysfunction. You have to worry about alcohol intake. You have to worry about fatty liver.

People know of methotrexate. Cyclosporin, it's really about renal dysfunction and blood pressure going up. It's a great drug in the short term, and I still use it in the short term, where I need to cool down some patients sometimes, but it's not a great drug for long-term safety.

Acitretin, I rarely use now. There's no really need these days. Apremilast, which I haven't mentioned yet, one of the newer oral drugs, it's real popular. A lot of people use it, basically saying it's safe. I would argue that, for example, the IL-23 biologics are safer than apremilast.

You have no side effects with IL-23 blockers. With apremilast, you have to worry about things like weight loss, suicidal ideation. The bottom line for me with apremilast, its efficacy is really poor. It's in the 30% range, and so it just really doesn't even compare with the biologic drugs, so I'm not really using apremilast.

I'm not alone in that, and I think that a lot of dermatologists are using it because it's easy to administer and give out. They're given samples, and so it's a lot of times easier to get patients off the ground with it, compared to a biologic, which has more paperwork involved.

To me, I just try to do the right thing for the patient. I usually give them the highest efficacy with the highest safety, and that often is an IL-17 or an IL-23 blocker.

Lauren:  I think that actually pretty much covers everything that we had questions on. Are there any other thoughts or anything that you would want to share regarding practice takeaways, maybe from your practice? Whether, again, practicing every day, away from trials, or your observations as someone part of clinical trials?

Dr Blauvelt:  My few take-home points are two. One is treat the patient as you would treat yourself. If you had psoriasis, what would you do? For example, if I had psoriasis, I would be on an IL-23 blocker. I encourage doctors to practice how they would want to be treated.

The second point is it's not that hard. Don't get overwhelmed. You can do it. These patients, if you just start using these drugs, they'll be your happiest patients. It's very rewarding these days. I tell patients, "You don't have to live with psoriasis anymore."

The drugs are so good these days, you really don't have to live with it anymore. We can often get to 100% clearance with no side effects. That is often happening right now in 2021.